Smoke Detector Disabled

Q: If a smoke detecting device is disabled for a breathing treatment (often for several days), what sort of fire watch, notification or signage is necessary?

A: None. Fire watches are not for a single device taken out of service, or for a single device found to be impaired. According to section A.9.6.1.6 of the 2012 LSC, it is not the intent of the Life Safety Code to require notification of the AHJ or evacuation (or fire watch) for the portion of the building affected for a single nonoperative device or appliance.

Also, section 9.6.1.6 of the 2012 LSC says where a required fire alarm system (not a single device) is out of service for 4 or more hours in a 24-hour period then an approved fire watch should be conducted. If this smoke detector is located in a healthcare occupancy, there may be a good chance that it is not a required device. Many designers add smoke detectors throughout hospitals where the LSC does not actually require them. In my opinion, you would need to have a branch or circuit disabled on a fire alarm system before a fire watch is required.

Strange Observations – Part 50

Continuing in a series of strange things that I have seen while consulting at hospitals…

We already talked about this issue on ‘Strange Observations – Part 20’ posted April 5, 2018, but it’s worth revisiting.

You cannot have home-made components installed on the fire alarm system. The threaded rod is not UL listed for this purpose.

 

NOTE: I’ve received some skepticism on the validity of saying the door release equipment is part of the fire alarm system. I base my position on section 21.8 of NFPA 72-2010, which says the door release equipment is a function of the fire alarm system, and according to section 10.3, all equipment used in conformity with NFPA 72-2010 must be listed for the purpose for which it is used. If the manufacturer of the door release device obtained a UL listing for the threaded rod, then I stand corrected. But as far as I know, that has not happened.

 

 

Duct Detector Test

Q: During our inspection our surveyor was looking for 3/8″ holes, 3 feet upstream, before the smoke detectors in the ductwork. He requested testing procedures for the duct detectors from the tester who stated the test was performed by putting smoke onto the duct detector, which shut down the air-handler unit. The surveyor says the smoke must be inserted 3 feet prior to duct detector to test the actual tube for blockages. Can you tell me the actual regulation that states this requirement?

A: According to NFPA 72-2010, section 14.4.2.2, the method to conduct testing of fire alarm systems must comply with Table 14.4.2.2:

14(g) Smoke detectors

1) Smoke detectors/smoke alarms shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol, acceptable to the manufacturer of the aerosol or the manufacturer of the smoke detector/smoke alarm and identified in their published instructions, shall be permitted as acceptable test methods. Other methods listed in the manufacturer’s published instructions that ensure smoke entry from the protected area, through the vents, into the sensing chamber shall be permitted.

6) Duct detectors

In addition to the testing required in Table 14(g)(1), duct smoke detectors utilizing sampling tubes shall be tested by verifying the correct pressure differential (within the manufacturer’s published ranges) between the inlet and exhaust tubes using a method acceptable to the manufacturer to ensure that the device will properly sample the airstream. These tests shall be made in accordance with the manufacturer’s published instructions for the device installed.

Here is a summary on how to test duct detectors:

  1. The test must ensure smoke/aerosol enters the sensing chamber and an alarm responds.
  2. You must verify the correct air pressure differential between the inlet and exhaust tubes, in accordance with the manufacturer’s instructions.

So, while the vendor appears to be testing the detector, it does not appear he is testing the air pressure differential of the inlet and outlet tubes. I don’t see anything in NFPA 72-2010 that requires putting smoke/aerosol in the actual air tube for duct detectors. I do see where that is required for air sampling smoke detectors, but duct detectors are not the same as air sampling smoke detectors.

Qualifications of Personnel

Q: We recently acquired a hospital that has been performing segments of their own fire system testing. What are the specific requirements or qualifications for an individual conducting testing or inspections on fire alarm systems and sprinkler systems?

A: NFPA 72-2010, section 10.4.3.1 requires a certified individual to perform service, testing, inspection and maintenance on fire alarm systems and components. The certification must be one (not all) of the following:

  • Factory trained and certified for the specific type and brand of systems being serviced
  • Persons who are certified by a nationally recognized certification organization (NICET, IMSA, etc.)
  • Persons who are registered, licensed or certified by the state
  • Persons who are employed and qualified by an organization listed by a national recognized testing laboratory for servicing fire alarm systems.

I have seen some larger hospitals that do employ people who meet one of the above requirements, but most hospitals contract this work to a qualified vendor who has these credentials. When it comes to sprinkler system testing/inspecting, NFPA does not require certification of the individuals performing the test/inspection. However, please check with your state and local AHJ to determine if they have additional requirements.

Fire Alarm System Strobes

Q: I work in a healthcare facility and we are in need to find an answer to a question regarding strobe lights. When we test our fire alarm system, and we silence the alarm, the strobe lights do not continue to flash. We were told that this is not “code” and the lights need to continue to flash even if system is silenced. I cannot seem to find this located in any part of the Life Safety Codes. Also, this is an older facility, so at some point/date do some healthcare facilities get grandfathered in if this is a newer code?

A: No… older facilities do not get to be grandfathered, or in any other way, exempt from complying with the code.

Section 19.7.1.4 of the 2012 Life Safety Code requires the transmission of the fire alarm signal during a fire drill. That means you cannot silence the audible alarms and you cannot disable the visual (i.e. strobe) notification devices. If you are doing either during a fire drill, then you are non-compliant and need to discontinue this practice and make sure the audible notification devices and the visual notification devices operate properly during each fire drill.

Now, having said that, there is one exception that you may qualify for and that is found in section 19.7.1.7 of the 2012 Life Safety Code, which says when drill are conducted between 9:00 pm and 6:00 am a coded announcement is permitted to be used instead of the audible alarms. But, the visual notification devices (i.e. strobes) must operate.

Fire Door Inspector

Q: My accreditation organization has a standard that says “testing and inspection of fire door assemblies needs to be conducted by a qualified person.” By what specifically do they mean when they say “qualified” and where are we able to find where they define their interpretation of what qualified is?

A: You will find the interpretation of what ‘qualified’ means under section 5.2.3.1 of NFPA 80-2010, which says functional testing of fire doors and window assemblies must be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. You may hire this responsibility out to a contractor with this knowledge and understanding, or you may assign the responsibility to test the fire doors to one of your own staff individuals, provided you ‘qualify’ them by determining they have the knowledge and understanding to perform this test.

If you decide on the latter, you need to document this decision by describing why you believe this individual has this knowledge and understanding of fire door operating components, and retain that document in case the surveyor asks to see how you qualified that individual. Your own staff individual could be qualified based on a certification course they may have taken (please understand there is no requirement that the person conducting the fire door inspections be certified, but it can be a good source of education), or the individual may be qualified simply because they have worked on doors for years and have accumulated this knowledge and understanding. The key is you may need to defend this decision, so it is best to document the decision and retain that to show to a surveyor.

Addressable Fire Alarm Systems?

Q: Are you aware of any accrediting organization requiring the hospital to have an addressable fire alarm system installed? If so, what organizations? Please explain the rationale and any supporting code behind this decision. Background: A hospital currently has a fully functional zone fire alarm system installed but heard that accrediting organizations are requiring addressable systems. In my review of NFPA 101 2012, I cannot find anything in chapters 18 or 19 that would differ from the 9.6 reference to NFPA 72 2010.

A: There is no NFPA Life Safety Code requirement for you to have an addressable fire alarm system. There is a requirement that the hospital have a fire alarm system that meets the requirements of 19.3.4 of the 2012 LSC, but that does not include being an addressable system. As far as I know, Joint Commission, HFAP, and DNV do not require an addressable fire alarm system, and CMS does not require an addressable fire alarm system.

Now, a state or local law may exceed the NFPA minimum and require an addressable fire alarm system, but you would have to check with your state and local authorities to find that out.

Off-Site Monitoring Station for Fire Alarm Systems

Q: I can’t seem to find anything in NFPA 72-2010 that says a facility is required to transmit a fire alarm signal to an off-site supervisory station. Our health care facility currently does not contract with an off-site station, and our procedure is to contact the fire department directly by phone when an alarm is received. Can you comment and provide some insight on this please?

A: Wait… what? This does not sound very good… What kind of healthcare facility are you? A hospital? An Ambulatory Surgical Center? According to the 2012 LSC, section 19.3.4.3.2.1 for hospitals, and section 21.3.4.3.2.1 for ASC, you need to comply with section 9.6.4 in regards to fire department notification. Section 9.6.4.2 requires that you communicate the fire alarm signal to the local fire department in one of the following methods:

  • Auxiliary fire alarm system
  • Central station fire alarm system
  • Proprietary supervising station fire alarm system
  • Remote supervising station fire alarm system

What you described is a manual transmitting system, which is not permitted for hospitals or ASCs. What I’ve observed most hospitals use is the Central Station Fire Alarm System which uses a modem to communicate to a central monitoring station that automatically relays any fire alarm signals to the local fire department. What you have described is a serious violation and one that CMS would consider to be a trigger for an Immediate Jeopardy decision. I suggest you get this resolved ASAP.

Fire Alarm System Communication

The answer to this question was provided by my good friend Gene Rowe, Director of Business Development for Affiliated Fire Systems, Inc., Downers Grove, IL

Q: With the impending discontinuation of the hard copper (POTS) phone lines, and in fact many municipalities already no longer have hard copper pairs from end user to the Central Office, are we, or will we be, in violation of the NFPA code for the primary DACT connection to the CO? Our fire alarm system company is telling us we must upgrade to another form of communication; however we have an IP based phone system in all buildings and the fire alarm company documentation indicates that IP based technology is acceptable, can I simply designate two analog phone lines from our system to the DACT, eliminating the POTS connection?

A: Per NFPA 72 (2010) Chap. 26.6.3.2, Patrick would be code compliant if he continues to use phone lines for a central station connection.  However, if the vendor is saying he must upgrade, it sounds like they’re discontinuing DACT monitoring.  He should verify that with the vendor.  Most central stations have DACT, radio and cellular receivers, but some are discontinuing DACT receiving for the reasons Patrick stated.  If he’s connected to a central station that’s dropping it, he may be able to find a new central station that still has it.  If he’s directly connected to a fire department that’s dropping it, he can see if he’s allowed to use a central station for monitoring.  If they’re not dropping DACT monitoring, he can ride that horse until discontinued by the monitoring agency or the lines die, but I’d advise setting up a new method so he can control the costs before it becomes an emergency.

Switching to IP based phone lines would still use the existing DACT transmitter, but without getting too technical, it comes with a couple of conditions:

  1. There has to be a dial tone on the IP phone lines when the receiver is picked up (loop started).  If you have to dial a number to get a dial tone (ground started), you can’t use it.
  2. The DACT communication out of the fire panel must now be converted into IP packets at the source, then reassembled into digital signals at the receiver.  That means the central station must have an IP converter & the end user must install an IP converter that matches it.
  3. The power for the phone system must be backed up by the emergency generator.

Obviously, bullet #2 is where the costs comes in & it won’t be cheap.  It may seem like it shouldn’t be a big deal, but changing communication methods always involves new equipment.  The costs & legwork involved in staying with phone lines may be more than installing the upgrade, which is probably a radio.

Strange Observations – Part 25

Continuing in a series of strange things that I have seen while consulting at hospitals…

I guess I like my smoke detectors mounted tight to the ceiling….